How is a high MACE (Major Adverse Cardiovascular Events) score managed?

From the Guidelines

Management of a high MACE score requires aggressive cardiovascular risk reduction through multiple interventions, prioritizing high-intensity statin therapy, antiplatelet therapy, blood pressure control, and lifestyle modifications to reduce the likelihood of future major adverse cardiovascular events. According to the most recent guideline 1, patients with a high MACE score should be managed with a comprehensive approach that addresses multiple risk factors simultaneously. This includes starting patients on high-intensity statin therapy such as atorvastatin 40-80mg daily or rosuvastatin 20-40mg daily to lower LDL cholesterol by at least 50%. Antiplatelet therapy with aspirin 81mg daily is typically recommended, and dual antiplatelet therapy with aspirin plus a P2Y12 inhibitor (clopidogrel 75mg daily, ticagrelor 90mg twice daily, or prasugrel 10mg daily) may be needed for patients with recent acute coronary syndrome or stent placement.

Blood pressure should be controlled to a target below 130/80 mmHg using medications like ACE inhibitors (e.g., lisinopril 10-40mg daily), ARBs, calcium channel blockers, or diuretics as appropriate. For diabetic patients, optimal glycemic control is essential, with preference for SGLT2 inhibitors or GLP-1 receptor agonists which have demonstrated cardiovascular benefits, as noted in the guideline 1. Lifestyle modifications are crucial, including smoking cessation, regular physical activity (at least 150 minutes of moderate-intensity exercise weekly), weight management targeting BMI <25, and a heart-healthy diet low in saturated fats and sodium.

The classification of cardiovascular risk factors into low, moderate, and high risk, as outlined in the guideline 1, can help guide the management of patients with a high MACE score. Regular follow-up every 3-6 months is necessary to monitor medication adherence, adjust therapy as needed, and assess for any new cardiovascular symptoms. This comprehensive approach addresses multiple risk factors simultaneously to reduce the likelihood of future major adverse cardiovascular events, as supported by the guideline 1.

Key considerations in managing a high MACE score include:

• Aggressive risk factor management to slow the progression of peripheral artery disease and prevent major adverse cardiovascular events, as recommended in the guideline 1
• Coordination of care through a multispecialty care team approach to promote collaboration and avoid potential duplication of care
• Assessment of functional status and quality of life to provide meaningful guidance for management decisions, as noted in the guideline 1
• Monitoring limb symptoms and functional status to assess the degree of functional status and quality of life, as recommended in the guideline 1.

From the FDA Drug Label

The primary endpoint was the occurrence of any of the major cardiovascular events: myocardial infarction, acute CHD death, unstable angina, coronary revascularization, or stroke. The effect of atorvastatin calcium 10 mg/day on lipid levels was similar to that seen in previous clinical trials. Atorvastatin calcium significantly reduced the rate of major cardiovascular events (primary endpoint events) (83 events in the atorvastatin calcium group vs. 127 events in the placebo group) with a relative risk reduction of 37%, HR 0. 63,95% CI (0.48,0.83) (p=0.001) Treatment with atorvastatin calcium 80 mg/day significantly reduced the rate of MCVE (434 events in the 80 mg/day group vs. 548 events in the 10 mg/day group) with a relative risk reduction of 22%, HR 0. 78,95% CI (0.69,0.89), p=0. 0002

Management of High MACE Score:

• The use of atorvastatin calcium has been shown to significantly reduce the rate of major cardiovascular events in patients with type 2 diabetes and those with clinically evident coronary heart disease 2.
• A high MACE score may be managed by initiating or intensifying statin therapy, such as atorvastatin calcium, to reduce the risk of major cardiovascular events.
• The dose of atorvastatin calcium can be titrated to achieve optimal lipid-lowering effects, with studies suggesting that higher doses (80 mg/day) may provide greater reductions in cardiovascular risk compared to lower doses (10 mg/day) 2.
• Additionally, management of a high MACE score may involve addressing other modifiable risk factors, such as hypertension, smoking, and diabetes, through lifestyle modifications and pharmacological interventions.

From the Research

Management of High MACE Score

A high MACE (Major Adverse Cardiovascular Events) score indicates a higher risk of adverse cardiovascular events such as myocardial infarction, stroke, or cardiovascular death. Managing a high MACE score involves several strategies, including:

• Identifying patients at risk using risk prediction models such as the 2MACE score 3, HEART score 4, or machine learning-based models 5
• Implementing preventive measures such as lifestyle modifications, medication adherence, and close monitoring of cardiovascular risk factors
• Using risk-scoring models to predict 1-year major adverse cardiac events after percutaneous coronary intervention (PCI) 6

Risk Prediction Models

Several risk prediction models are available to predict MACE, including:

• 2MACE score: a predictor of major adverse cardiovascular events in patients with atrial fibrillation 3
• HEART score: a predictor of major adverse cardiac events in patients presenting with chest pain 4
• Machine learning-based models: can be used to predict 5-year risk of MACE 5
• Risk-scoring models: can be used to predict 1-year major adverse cardiac events after PCI 6

Limitations of MACE Definitions

There is variability in the definition of MACE used in observational studies, which can limit the comparison and replication of findings 7. It is essential to use standardized definitions and validated outcome measures to improve the accuracy and reliability of MACE predictions.

Clinical Implications

Accurate prediction of MACE can help identify patients at high risk and inform clinical decision-making. By using risk prediction models and implementing preventive measures, healthcare providers can reduce the risk of adverse cardiovascular events and improve patient outcomes 3, 5, 4, 6.